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Aquabirths was delighted to read this lovely birth story by Jo, published by doula Cathy Williams. Jo had her first baby by caesarean when she found that her baby was breech when she went into hospital in labour, and she was told by hospital staff that she had no other option (which isn’t true!).

For Jo’s second baby, she was very interested to find that her consultant was very supportive of a VBAC – a vaginal birth after previous caesarean birth(s). Jo had previously thought that she would not be able to have a vaginal birth, having had her first baby by caesarean. In fact, VBAC is very often the safest option for women who would prefer a vaginal birth.

After extensive research, Jo decided that she would like to birth in a birth pool on the midwife led unit, and this is exactly what happened. Thanks to the support of her doula, Cathy, Jo’s research and strong self advocacy, and as Jo herself puts it, “some balls”, Jo birthed her baby how she wanted, in a birth pool, with only the interventions that she was happy to accept.

Congratulations from all of us at Aquabirths, Jo, and thank you to Cathy Williams for sharing Jo’s story!

This is a lovely article with some very helpful information for midwives and other carers of pregnant women who are plus size. It’s so important to remember that larger women are not necessarily less healthy than slimmer women- and even if they do have medical conditions related to their weight, they still need and deserve personalised care.

And of course, labour and birth in water offers huge benefits to women of all sizes, and women should not be denied access to water just because they are “plus size”.

The OASI Bundle refers to a specified list (the Bundle) of interventions which are being evaluated to see whether they reduce the numbers of very serious tears during birth, known as OASI, which affect the woman’s anal sphincter. The package is outlined by RCOG here. These types of tears can be hard to repair, and can lead to life changing injuries for women. While Aquabirths absolutely supports the concept of trying to reduce the chances of these types of birth injuries, there are some serious concerns about the OASI Bundle and whether it is the best way to achieve this.

Communication with women about their chance of OASI (more about this in a moment)

Using the “Finnish Grip” as the baby is born

Use of episiotomy as per indications in the details of the Bundle

Checking the mother by inserting a finger into her rectum and feeling for tears which might not be immediately obvious and which can be present even if her perineum is intact.

We were initially pleasantly surprised to see a list which specifically included the requirement to speak to women about the intervention. While sometimes a guideline will say “do X with consent”, rather than just “do X”, it is very exciting to see a specific component of a Bundle being that women should be making an informed decision to be a part of a trial. However – despite being the first part of the Bundle (after all, nothing can be done without consent) the fact that this component is listed last in RCOG’s detailed guidelines speaks volumes about the consideration of its importance. Even more worryingly, in practice, midwives are reporting that women are arriving at hospital in labour without having been given information about the Bundle by their community midwife and therefore ensuring that ensuring that informed consent is given is much harder. This should itself invalidate the data that is being collected by the trial, according to its own rules, and performing any intervention on women without informed consent is, in law, common assault.

The Finnish Grip is the main intervention in OASI. It involves gripping the perineum with the intention of redirecting pressure towards other vaginal and labial tissues. This video shows it in practice (keep the sound off – the artificial sound effects are somewhat irritating, especially the “push-push-push”!) You will note from the video that the “woman” is on her back, pushing against gravity with her baby’s head therefore pressing down hard against the perineum. The Finnish Grip is designed to push the baby’s head up and away from the perineum – yet encouraging women to be upright or forward facing has the same effect! With an upright, forward facing or even side lying position the baby’s head is lifted by gravity towards the woman’s front, rather than being dropped by gravity heavily onto the perineum. The Finnish Grip also displaces the pressure of the baby’s head towards the clitoral area, and this causes increased numbers of tears in this area, often with serious loss of sexual feeling for women. These tears are considered to be less severe than anal sphincter tears (although partly this is because reduction of female sexual function is often considered to be of less importance than it is to the individual woman) – and again, we would not want for a moment to understate the catastrophic consequences of these – but what if there is another way?

What we know about perineal trauma is that women who birth on their backs, perhaps in lithotomy, are more likely to experience serious tears than women who birth in upright positions. Women who birth in water experience fewer serious tears, and the OASI Bundle cannot be used in water. The evidence around waterbirth reducing the incidences of severe tears has been well known for years, and we welcome hearing HCPs suggesting waterbirth to women who are worried about their personal risk of a severe tear, or who are at higher risk of it.

We also know that some obstetric interventions can increase the risk of OASI. For instance, inductions and epidurals lead to a higher chance of birthing lying down or in lithotomy, which as I’ve already discussed leads to gravity pulling the baby’s head more firmly down onto the perineum. However, the very low rates of severe tears in women who birth without pharmaceutical pain relief (allowing them to follow their instincts more clearly and leaving them with the sensations from their bodies to respond to), especially in low-medicalised environments such as home births or midwife led unit births, lead many to feel that there are other ways to reduce OASI without pinching a woman’s genitals as she is trying to push a baby through them.

Many midwives have noted how women will naturally close their legs together to slow the birth of the head – and yet how many women are encouraged to open their legs to “make space for the baby”? In artificial birth positions such as lithotomy, this is simply not possible, which may explain the higher numbers of tears which the Bundle is trying to reduce.

Margaret Jowitt has introduced an interesting theory that in upright or forward leaning birth, the baby’s head presses against the clitoris (again, as the pressure is spread towards the opposite side to the perineum), and in a spontaneous birth where the woman’s and baby’s bodies are working together the baby’s head could be “cushioned” by the the internal parts of the clitoris, (the bulbs and the crura), triggering it to enlarge and gently support the baby as the head passes through and out of the vagina. Midwife Joy Horner discusses the need for the vaginal and perineal muscles to soften and relax, much like is needed for comfortable love making, and a supportive, loving birth environment with a known and trusted care giver (continuity of carer!) who would not interfere with that oxytocin creation could explain why independent midwives have such low rates of OASI.

It is deeply worrying that we are seeing signs, during this OASI trial, that women are not being given information antenatally to ensure that they can give informed consent during their birth despite the fact that this is a key part of the Bundle. The Finnish Grip appears to be trying to rectify a problem which may well be caused in the main by over-medicalising birth and not supporting women to follow their instincts, and the damage that the Finnish Grip can cause with the associated increase in labial and clitoral tears may cause more women problems than would have suffered with anal sphincter tears. Instead of rolling out yet more intervention, perhaps it’s time to take a step back and look at supporting more women to birth in water, or to have more continuity of carer to ensure that during one of the most intimate periods of their lives, women and their carers can feel the deep and loving bond that even the very best, most caring midwives cannot be expected to develop when they meet for the first time in a hospital setting.

Aquabirths’ birth pools are designed to provide space and support for an active birth, but for women who do not want to use a birth pool but still want a hospital birth, or for the very rare woman for whom it’s not medically possible to use a birth pool, this fabulous video provides ideas of ways to use the hospital room space to lean, rock and move. Don’t miss it!

Alongside midwifery units are defined as midwife-led units which are on the same premises as an obstetric unit (OU). They are usually next to the OU and may have come about following restructuring of the OU.

A follow on study from Birthplace 2011 investigated the way that alongside midwifery units are organised, staffed and managed, as well as the experiences of the women who use them and the staff who work in them.

The researchers looked at 4 different alongside midwifery units. They interviewed midwifery staff and service users, and also those in a management and organisational role. What became clear from the study was the fact that midwives working in alongside midwifery units were able to practice more autonomously, using their own clinical judgement. This is how all midwives, who are all autonomous practitioners, should be able to work, but obstetric units often discourage or reject this aspect of the midwifery role. Midwives also reported how they valued the work environment and culture, although the study did acknowledge that there was a need to ensure that midwives were supported to continue to develop their confidence, which is not a surprise as so many would have been trained in a far more repressive environment.

Another challenge for the sustainability of the alongside midwifery units was the fact that of all of the women who were considered to be good candidates to birth there, only a third ended up doing so. This study does not look at why this might be, but we know from feedback from women that very often they are simply not made aware of the midwife led unit in their area, so they did not have the opportunity to consider it for their baby’s birth.

Ultimately, Aquabirths would like to see the facilities which are commonplace within a midwife led unit such as birth pools, birth couches, mats and birthing balls, as well as the environment which is designed for calm, and to promote oxytocin, available as standard within all types of units, including obstetric units. There is no reason why these facilities could not be used by far more women, and we strongly believe that if a better birth environment was available to all, that more women would birth their babies with fewer unnecessary interventions. We hope that more research like this will encourage designers of all types of maternity units to create spaces which support both women and midwives to work together for better births.

An Australian study has looked at how midwives there perceive the value of waterbirth, and how well they are able to support it within their working environments.

The study outcome was very positive, with midwives reporting that both water labour and birth were very helpful to women, and they “documented benefits of reduced pain, maternal relaxation and a positive birth experience”.

Despite this, the midwives also reported, “…that policy/guideline documents limited their ability to facilitate water immersion and did not always to support women’s informed choice.” , a situation that we see so often over here in the UK. It is time to support women to access the many benefits to them and their baby that comes with immersion in water for labour and birth, and to treat each woman as an individual rather than as a “risk factor”.

The Australian study mentions that “negative attitudes” are a barrier to providing access to birth pools. Quite rightly, there would be an outcry if “negative attitudes” prevented women from being able to have an epidural, and yet the risks of an epidural are well documented, whereas labouring and birthing in a birth pool has an extremely small list of concerns. One is, of course, what to do if a woman collapses while she’s in the birth pool. Tried and tested management guidelines are well established for this situation, which itself is extremely rare, but there is a worrying trend for women with higher BMIs to be denied access to a pool because they might be harder to bring out if they are unconscious. Another is the challenge of judging blood loss, but this is a skill that midwives who support waterbirth quickly learn. In “Revisiting Waterbirth”, Dianne Garland – expert waterbirth midwife – gives a helpful explanation of how the water should look when blood loss during or after a waterbirth is within normal ranges although of course there are many other factors such as how the woman is looking and feeling.

In summary, it is great to see a study showing midwives who are so positive about waterbirth, and the study seems to show that this is representative of many midwives in Australia, as is the case in the UK. The barriers come from attitudes from medical colleagues who need to be made aware of the work already done to deal with the concerns that they may have.

Each birthing room at the Auckland based “Birthcare” birthing centre in New Zealand has been upgraded to take the bed away from the focus of the room, and instead create a harmonious birth space with the pool and couch as the main furniture items.

Including mood lighting (choose the colour that you like best), sound systems, bean bags and birth balls, these stunning birth rooms provide a secure and comfortable space for women to birth their babies safely.

The Birthcare centre offers services seldom seen in even the best UK birth centres, such as an onsite paediatrician to avoid unnecessary transfers to hospital for non-emergency treatment, and an in-house lactation consultant service which women can self-refer back to after discharge should they need more assistance with breastfeeding.

Many of our own UK birth centres have these wonderful facilities, including our own Aquabirths birth pools and Softbirths birth couches, mood lighting, sound and the obstetric bed either absent or hidden. We urge more trusts to follow this route, support birth centres and also support these facilities within the obstetric unit, to help more women to have physiological births.

In Part 1 of this blog I discussed how companies need to build innovative products together with clinicians, in order to work out what helps them and their patients, rather than companies making assumptions about medical needs which may not actually be valid, which can create barriers to innovation.

Another barrier to innovation in the NHS which was raised in the Nuffield Trust’s report (link) was that, “Products are sought which lead to short-term savings, rather than transforming care pathways leading to more efficient services”.

Stories of NHS managers introducing cheaper versions of products which turn out to be more expensive overall are rife: examination gloves which split, and two or three are wasted before a useful pair is found. Paper towels which don’t come out of the dispensers properly, and end up being wasted on the floor. But far more worryingly – spending money on areas which do not improve care, and can actually hinder it.

Far cheaper investments, such as birth pools, also leads to significant cost savings. Labouring in water increases the rate of spontaneous vaginal births, reduces the need for instrumental delivery, reduces the numbers of 3rd and 4th degree tears, lowers the chance of a woman wanting opiate pain relief or an epidural, and increases women’s positive experiences of birth which might lead to lower levels of PND. (1) ALL of these mean that the NHS spends less money on fixing the consequences of these interventions, as well as the cost of the intervention itself.

Let’s see the NHS looking at the wider picture with every new innovation or investment. We call upon commissioners to look past the cost of installing new equipment which supports women to birth more easily, and instead see the full spectrum of ways that an investment in a birth pool, or other normal birth promoting products, can save the cash-strapped NHS money, while leading to better outcomes for women and their babies.

While many barriers to new innovation in the NHS are well documented, the Nuffield Trust has released a report which looks at areas which have received less focus, and yet which are key to change.

Two of the main barriers listed were:

Lack of clinician time to identify problems, and to work with companies to provide solutions

Products are sought which lead to short-term savings, rather than transforming care pathways leading to more efficient services – I will discuss this in the next blog.

Lack of clinician time to identify problems and to help to work with innovators to find solutions is a problem which is certainly not limited to the NHS. All industries provide insufficient resources to allow staff the time, space and training to sit back and look at where problems are, and to work on solutions to those problems. In the NHS this leads to solutions being offered by companies which have not always been designed together with the clinicians, or the users of those products.

Two nurses wearing old fashioned starched caps

Sometimes a problem is identified and the solution put forward does resolve a problem, but causes another because the designer doesn’t work within the care setting. Although this isn’t a clinical product example, it underlines the problem well: In the 80s, some female nurses still wore starched fabric caps (male nurses were not required to as the fashion followed nurses originally being primarily nuns, and then the Victorian era of women needing a head covering). I well remember my own mother spending hours over the ironing board spraying starch onto her nursing caps. One day she told us that they were moving from the fabric cap to a disposable cardboard version (at a daily cost of 2p per cap to the NHS). Rather than working out whether the cap was a relic from the past which interfered with clinical care and should be removed from the uniform, the solution to the complaints of female nurses that they spent hours getting their caps stiff and sturdy was resolved with an expensive and pointless alternative product.

Aquabirths’ Heart-Shaped Birth Pool

Aquabirths is lucky to have worked with midwives right from the start of the design of all of our birth pools. Pictured is our heart shaped birth pool which was designed together with midwives from Leeds, Yorkshire, UK. They requested featured such as:

A freestanding pool to enable midwives and birth companions to be able to easily support the birthing woman from any side of the birth pool.

A larger birth pool to offer comfort and support to even the tallest women.

Smoothed edges to ensure comfort for women and midwives leaning over the edge of the birth pool, often for long periods of time.

A single surface birth pool to ensure that it can easily and thoroughly be cleaned.

Aquabirths continues to work with midwives and birthing women to ensure that our birth pools are designed just how the users of our pools need them to be, and we hope to see more of a trend across the NHS to working this way with product manufacturers.

Oldham, in Greater Manchester, UK, has created the most stunning, supportive and effective birth centre which is family-centred and woman friendly. Designed to nurture women and birth, creating a safe, positive and caring space for the whole family – including other children, who can be present at the birth of their sibling.

Designed to support the physiology of birth from the ground up, the Birth Centre rooms do not centre around an obstetric bed. Instead, they feature slings, balls, mats, Softbirth couches, adjustable lighting and the stunning Aquabirths birth pool, with a large family bed available for parents and baby to rest in after their little one is born.

The Oldham Birth Centre’s philosophy of care is key to the success of this midwife-led maternity unit. Midwives are trained in hypnobirthing techniques, aromatherapy, acupuncture and using water to support positive, safe, physiological birth. Minimising adrenaline is key to maximising oxytocin, and maximising oxytocin is key to birth progressing well, so the whole room is designed to be calm and to help everyone to relax. An aromatherapy diffuser by the door greets the birthing family as they arrive, and the scents in the air, the dimmed lights offset by coloured bubble lamps and the Aquabirths birth pool gives a sense of walking into a spa.

Oldham Birth Centre Wall Painting

Midwives describe seeing women sitting in a chair and looking around, and visibly relaxing. A kitchen is available for all to use, so birth partners can help themselves to drinks, and they can make their own snacks. Midwives make it quite clear that this space is for them to use, which is an important part of helping everyone to relax and continue to reduce any adrenaline levels.

The Oldham Birth Centre is not an extension of the labour ward, but instead is designed as a birth centre for the families of the city. While there are strict criteria for straightforward access to the unit, if a woman wants to birth there she can attend a Birth Options Clinic where their choice of place of birth is discussed, and the woman will be supported by the midwives.

The unit itself is nothing without its midwives, and the midwives at Oldham are hand picked for their inbuilt nurturing nature – not a trait which can be taught. Diane watches the student midwives who show an interest in physiological birth and support women’s choices. Those who wish to become part of the community/birth centre team are encouraged to apply.

Oldham Birth Centre is not unique, but it is unusual and it is beautiful. The women and families of Greater Manchester are extremely lucky to have this wonderful facility with its fabulous midwives.
The unit has a video on You Tube which showcases the birth pool and other facilities: https://www.youtube.com/watch?v=2wOHqJfLhGg